u-sacramentodistrict（8页）.docVIP

U.S. Army Corps of Engineers South Pacific Division Nationwide Permit Pre-Construction Notification (PCN) Form This form integrates requirements of the U.S. Army Corps of Engineers Nationwide Permit Program within the South Pacific Division (SPD), including General and Regional Conditions. You MUST fill out all boxes related to the work being done. Fillable boxes in this form expand if additional space is needed. Box 1 Project Name ????? Applicant Name ????? Applicant Title ????? Applicant Company, Agency, etc. ????? Applicant’s internal tracking number (if any) ????? Mailing Address ????? Work Phone with area code ????? Mobile Phone with area code ????? Home Phone with area code ????? Fax # with area code ????? E-mail Address ????? Relationship of applicant to property: Owner Purchaser Lessee Other: ????? Application is hereby made for verification that subject regulated activities associated with subject project qualify for authorization under a U.S. Army Corps of Engineers Nationwide Permit or Permits as described herein. I certify that I am familiar with the information contained in this application and, that to the best of my knowledge and belief, such information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby grant to the agency to which this application is made the right to enter the above-described location to inspect the proposed, in-progress or completed work. I agree to start work only after all necessary permits have been received and to comply with all terms and conditions of the authorization. Signature of applicant Date (mm/dd/yyyy) ????? If anyone other than the person named as the Applicant will be in contact with the U.S. Army Corps of Engineers representing the Applicant regarding this project during the permit process, Box 2 MUST be filled out. Box 2 Authorized Agent/Operator Name ????? Agent/Operator Title ????? Agent/Operator Co